Urgent Laparotomy Research Articles

EGS SO03 - Audit of wound complications after Emergency laparotomies in A University Teaching Hospital: 2-cycle Prospective Audit

Abstract Background Wound infections and incisional hernias are frequent complications that can occur after an emergency laparotomy. The surgical technique used plays a crucial role in determining the likelihood of complications. The objective of this audit was to evaluate our technique in performing emergency midline incision closure and to compare our complication rates with those of established guidelines. Method A two-year prospective audit, comprising two cycles, was conducted at a teaching university hospital to evaluate the incidence of wound infections following emergency laparotomy. During each cycle, which lasted for one year, 1423 patients underwent an emergency laparotomy. Results The initial outcomes showed that wound infection rate was 123 out of 621, which translates to 19.8%, the overall rate of acute fascial rupture was 66 out of 621, amounting to 10.6%, while overall incisional hernia rate was 87 out of 621, which equals 14%. In the subsequent cycle, wound infection rate was 49 out of 802, corresponding to a percentage of 6.2%. The overall rate of acute fascial rupture was 34 out of 802, which is equivalent to a percentage of 4.3%, while the overall incisional hernia rate was 42 out of 802, which translates to 5.2%. Conclusion In conclusion, the audit revealed several areas of improvement to address in order to enhance its overall performance and achieve its goals of decreasing our rate of wound complications after urgent laparotomy which needs our adherence to this closure technique

Bronchiolite inconsolabile, l'addome è trattabile?

Some viruses, such as adenovirus, have been associated with an increased risk of intussusception, although the link in community infections is less clear than with the rotavirus vaccine. The paper presents the case of a 3-month-old infant hospitalized for bronchiolitis, who subsequently developed irritability and gastrointestinal bleeding and refused to eat. The diagnosis of ileocolic intussusception was confirmed via barium enema and required urgent laparotomy for reduction. The post-operative course was uneventful with discharge on the fifth day. This case highlights the importance of monitoring infants with bronchiolitis to find possible signs of intussusception.

060. Chronic Megacolon with Recto Vaginal Fistulo Associated with Atresia Ani: A 26-Year History and Case Report

Background: Large bowel obstruction and megacolon formation with rectovaginal fistule ascociated with atresia ani is rare. abnormal colon dilatation that falls into one of three categories: toxic, chronic, or acute. Acute megacolon, sometimes called Ogilvie syndrome, is a condition that frequently affects sick or postoperative individuals and is linked to autonomic nervous system dysfunction. Its source is unknown. On the other hand, intestinal dysfunction brought on by neurological or muscle conditions is the cause of chronic megacolon. The symptoms of all three kinds include bloating, stomach pain, and constipation. Case: We present a case of an 26-year-old woman surviving large bowel obstruction and mega-megacolon formation secondary atresia ani and fistulo rectovagina for 26years alive, with an presentation of abdominal distention. Results The patient’s symptoms, laboratory test results, and imaging were consistent with large bowel obstruction. The patient underwent urgent exploratory laparotomy. Upon entry in the abdomen, it was unexpected that the extreme colonic wall thickening, indicating the longtime course of illness. In this instance, we performed a number of procedures, including ligation of the obstructed colon, anus repair, and vaginal fistula repair. Conclusion: This report aims to point out the atypical and in-extremes presentation of an otherwise common disease.

Trauma Program Value Assessment at an Academic Health Network System Over 12 Years.

Trauma is a leading cause of global death, with 200000 deaths and over 3 million non-fatal injuries/year in the United States. We aim to assess trauma care value for patients who underwent urgent laparotomies (LAP) and thoracotomies (THO) in our Health Network System. Clinical variables (v = 84) from trauma patients (>18 yo) were retrieved retrospectively (Jan-2010 to July-2016) and prospectively (Aug-2016 to Sept-2021) from a Health System warehouse under IRB-approved protocols. Patients were divided according to their Injury Severity Score (ISS) into mild/moderate cases (ISS <15) and severe cases (ISS >15). Value was assessed using quality and cost domains. Quality surrogates included graded postoperative complications (PCs), length of stay (LOS), 30-day readmission (RA), patient satisfaction (PS), and textbook (TB) cases. Total charges (TCs) and reimbursement index (RI) were included as surrogates for cost. Value domains were displayed in scorecards comparing Observed (O) with Expected (E) (using the ACS risk calculator) outcomes. Uni-/multivariate analyses were performed using SPSS. 41,927 trauma evaluations were performed, leading to 16044 admissions, with 528 (3.2%) patients requiring urgent surgical procedures (LAP = 413 and THO = 115). Although the M:F ratio (7:3) was similar in LAP vs THO groups, age and BMI were significantly different (41.8 ± 19.1 vs 51.8 ± 19.9 years, 28.6 ± 9.9 vs 27.4 ± 7Kg/m2, respectively, P < .05). Blunt trauma was involved in 68.8/77.3% of the LAP/THO procedures, respectively (P < .05). Multivariate analyses showed ISS, age, ASA class, and medical center as factors significantly predicting PC (P < .05). Postoperative complication grades from the LAP/THO groups showed above-average outcomes; nonetheless, LOS was higher than the national averages. The Trauma Program holds high value in our Health Network System. Protocols for decreasing LOS are being implemented.

Management of a Rare Case of Superior Mesenteric Artery Aneurysm Associated with a Pancreatic Cyst Complicated by Acute Rupture: A Case Report and Review of Literature

Superior mesenteric artery aneurysms are a rare pathology, and rupture due to a pancreatic cyst in the context of alcohol-induced pancreatitis is an even rarer condition. The first line of treatment is usually an endovascular approach. We present the case of a 51-year-old male with alcohol-induced pancreatitis, diagnosed with a superior mesenteric artery aneurysm with active bleeding in close contact with a large pancreatic cyst. A covered stent was used to treat this condition. The patient developed hemorrhagic shock 12 h after the procedure and an urgent laparotomy was performed. A second rupture of the arterial wall at the distal end of the stent was observed and in order to obtain distal perfusion, first, an infrarenal aorta to superior mesenteric artery bypass distal to the rupture was performed in order to exclude the aneurysm. Secondly, a bypass originating from the distal end of the first bypass to the distal end of the superior mesenteric artery was performed. The patient had an uneventful recovery and was discharged after 10 days. We reviewed the literature regarding the incidence and the therapeutic management of superior mesenteric artery aneurysm complicated by pancreatic cyst. An advanced search on PubMed from 2004 to 2024 returned 194 results and after applying the inclusion–exclusion criteria, 11 publications were selected. Although the endovascular approach is usually the first line of treatment with obvious advantages for the patient, a patient-tailored approach should be made in such cases and surgery could be the first option, when considering that the mechanism of aneurysm rupture is due to erosion of the arterial wall by the pancreatic enzymes. Surgery has the advantage of cyst drainage and aneurysm exclusion and in our case proved lifesaving.

Evaluating predictors of mortality in octogenarians undergoing urgent or emergent trauma laparotomy.

This study aimed to identify associated risk factors for mortality in octogenarian trauma patients undergoing urgent or emergent laparotomy (UEL). Trauma patients ages 80-89 years-old undergoing UEL within 6-hours of arrival were included. A multivariable logistic regression analysis was performed to determine associated risk of mortality. From 701 octogenarians undergoing UEL, 324 (46.2%) died. Compared to survivors, UEL octogenarians who died had higher rates of cirrhosis (3.5% vs. 1.1%, p = 0.028), injuries to the brain (17.3% vs. 5.6%, p < 0.001), heart (8.6% vs. 1.6%, p < 0.001), and lung (57.4% vs. 23.9%, p < 0.001) and lower rates of functional independence (6.4% vs. 12.6%, p = 0.007). The strongest independent associated patient-related risk factor for death was cirrhosis (OR 8.28, CI 2.25-30.46, p = 0.001). However, undergoing concurrent thoracotomy increased risk of death significantly (OR 16.59, CI 2.07-132.76, p = 0.008). Functional independence was not associated with mortality (p > 0.05). This national analysis emphasizes the need to identify and manage pre-existing conditions like cirrhosis and not determine futility based on pre-trauma functional status alone. Concurrent thoracotomy for hemorrhage control increases risk of death over 16-fold.

Radio-Histopathological Spectrum of Ovarian Specimens Following Cystectomy

Ovarian cysts can be benign or malignant and requires accurate diagnosis for efficient treatment. Objective: To characterize the radiological and histopathological spectrum of ovarian specimens following cystectomy. Methods: This retrospective study was conducted at Pakistan Atomic Energy Commission General Hospital, Islamabad from 1st April 2022 to 31st December 2022.Eighty patient’s samples from cystectomy patients who were suffering from ovarian cysts were included. Each patient underwent radiological examination before ovarian cystectomy through laparoscopic surgery except two cases of urgent laparotomy. Gross histopathological specimen examination was conducted. The data were analysed using SPSS version 26.0, wherein p value &lt;. 0.05 was considered as significant. Results: The mean age of the patients enrolled in this study was 35.5±5.9 years. Hemorrhagic cysts were having a reticular pattern of internal echoes with soli appearing area with concave margins and no internal flow, while endometrioma cysts were having homogenous low level internal echoes with non-solid component and tiny echogenic foci in the walls. While within the neoplastic cysts 4/8 werehaving cystic external surface and 1/8 presented with ovarian mass.The surface epithelial tumor presented of 2 cases with carcinoma detection on histopathology slides while in the germ cell tumor 1 cases each of strumaovarii, dysgerminoma and mixed germ cell tumor was observed. Conclusions: Surface epithelial tumors were the most common category of ovarian tumors and majority of the cysts were benign cystadenomas. Radiological imaging provides a precise non-invasive tool for categorizing various ovarian cysts and histopathological findings further confirms the exact category of tumors.

A Rare Case of Ruptured Heterotopic Pregnancy after Natural Conception Demanding Immediate Attention

Objective. We present the case of a ruptured heterotopic pregnancy after natural conception and its management during hospi- talization. Case Report. The patient presented to the emergency department of our hospital with symptoms of lower abdominal pain and vaginal blood loss. She reported a confirmed intrauterine pregnancy at 8 weeks’ gestation following natural concep- tion. The patient was admitted to the hospital with the diagnosis of a ruptured ovarian cyst. Due to hemodynamic instability, an urgent exploratory laparotomy was performed. The histological review showed an ectopic fallopian pregnancy, confirming the final diagnosis of an heterotopic pregnancy. Conclusion. Heterotopic pregnancy is a very rare condition, even more so if it happens spontaneously. As a result, it has been insufficiently studied in relation to proper management and timely diagnosis.

Rupture of fetal membrane in ectopic tubal pregnancy: A case report and literature review.

Ruptured tubal pregnancies occurring in the second trimester are rare; yet, they pose a critical risk of life-threatening hemorrhage. This study aims to highlight the importance of timely surgical intervention in such cases to prevent fatal outcomes. The case underscores the diagnostic and therapeutic challenges that arise when distinguishing between tubal and abdominal pregnancies, particularly in the presence of hemoperitoneum, which can obscure imaging results. We present a case involving the spontaneous rupture of a tubal pregnancy at 15 weeks and 3 days of gestation. The patient exhibited elevated beta-human chorionic gonadotropin levels. Initial transabdominal ultrasound suggested an abdominal pregnancy, and computed tomography scans supported these findings. Urgent midline laparotomy revealed the condition to be a tubal pregnancy, contrary to initial imaging. The surgical procedure included the removal of the gestational sac and the affected fallopian tube, followed by abdominal closure. Hemoperitoneum was noted to compromise the accuracy of imaging modalities, complicating the preoperative diagnosis. Histopathological examination confirmed the diagnosis of tubal pregnancy. The patient had an uneventful recovery and was discharged 7 days post-surgery with stable hemoglobin levels. This case underscores the importance of considering the differential diagnosis of abdominal versus tubal pregnancy in the presence of hemoperitoneum, due to their differing clinical management needs. It offers insights that may guide clinicians in the timely diagnosis and treatment of advanced tubal pregnancies, where prompt surgical intervention is critical.

Spontaneous rupture of hepatic hemangioma: case report and literature review

Hepatic lesions represent a potential etiology of spontaneous hemoperitoneum. Among these, hepatic hemangiomas, characterized by congenital vascular malformations, stand out as the most likely benign liver neoplasms, frequently presenting as asymptomatic entities. However, spontaneous rupture constitutes the gravest complication associated with these lesions, underscoring the imperative of prompt diagnosis. Notably, the global mortality rate attributed to spontaneous rupture of hepatic hemangiomas remains elevated. Hence, achieving an accurate diagnosis of this condition is paramount for informing. Hepatic hemangioma stands as the prevailing benign hepatic neoplasm, with autopsy studies indicating a prevalence ranging between 3% and 20%. In a clinical scenario, a 64-year-old patient presented at Sant’Anna and S. Sebastian Hospital with severe abdominal pain, hypotension (blood pressure 70/40 mm Hg), tachycardia (heart rate 120 bpm), and abdominal muscle guarding upon physical examination. Ultrasound assessment revealed the presence of free intraperitoneal fluid. However, the ultrasound examination could not be completed due to the patient’s deteriorating hemodynamic status and manifestation of instability. Consequently, an urgent exploratory laparotomy was deemed necessary and promptly undertaken in the operating theater.

Surgical Treatment of Complicated Chronic Pancreatitis: Nine Years of Experience

Aim. To analyze and demonstrate the potential of surgical treatment for patients with chronic pancreatitis and its complications in a department of general surgery, and to develop treatment strategies for patients with pancreatogenic pseudocysts in the subdiaphragmatic space and mediastinum.Materials and methods. This study presents the experience of treating 955 patients with complicated chronic pancreatitis over nine years, including an analysis of the treatment of 13 patients with mediastinal pancreatogenic pseudocysts. There was no pre-selection or distribution into groups. All patients underwent a comprehensive examination, including ultrasound, CT, and MRCPG. Endoscopic retrograde cholangiopancreatography was not performed due to the procedure’s complexity and potential for severe complications. Depending on the nature of the pancreatic pathology and its complications, a combination of conservative and surgical treatment methods was selectively employed.Results. A total of 570 patients (59.7 %) received conservative treatment, while 385 patients (40.3 %) underwent surgical procedures, subdivided into resection, internal drainage, and external drainage. 121 patients (31.4 %) had a resection, including pancreatoduodenal resection (17), Frey’s operation (74), caudal resections (21), and others (9). 33 patients (8.6 %) underwent internal drainage operations, including the Puestow operation (15), hepaticojejunostomy (7), and others (11). Additionally, 231 cyst-related procedures were performed: Frey’s operation (7), cystojejunostomy (12), cystectomy (11), urgent laparotomy (15), and external drainage under ultrasound guidance (186). Of the 156 resection-drainage operations, Frey’s surgery was the most frequent (81 patients; 51.9 %). The postoperative mortality rate was 0.8 %.Conclusion: Surgical indications should be determined based on clinical presentation and diagnostic methods, prioritizing organ preservation whenever possible. The treatment of complicated pseudocysts should be tailored to each patient, emphasizing minimally invasive interventions. External-internal drainage of pancreato-digestive anastomoses through the proximal section of the isolated jejunum is recommended.

Airway breathing circulation dengue: a case of multifactorial shock due to major trauma and severe dengue infection

BackgroundDengue is the most common arboviral illness reported globally, endemic to most tropical and sub-tropical regions of the world. Dengue Shock Syndrome is a rare complication of severe Dengue infection resulting in haemorrhagic complications and refractory hypotension. We report on a case of severe dengue diagnosed in a patient with major trauma and illustrate some of the potential challenges and considerations in the clinical management of such cases.Case PresentationA 49-year-old female presented following a road trauma incident with multiple abdominal injuries requiring urgent laparotomy. Her recovery in Intensive Care Unit was complicated by the development of Dengue Shock Syndrome characterised by a falling haemoglobin and platelet count, multiorgan dysfunction and prolonged hospital stay.ConclusionsDengue Shock Syndrome may complicate fluid management and bleeding control in major trauma cases. Awareness of Dengue, particularly in endemic areas and returned travellers may help facilitate early diagnosis and management of complications.

Problematic issues of diagnosis and treatment of Boerhaave’s syndrome

Boerhaave’s syndrome is a rare disease with an incidence of 3.1/1,000,000 per year, has a high mortality rate due to late diagnosis and difficulty in treatment. The purpose of the message is to draw the attention of doctors to the variety of clinical manifestations of Boerhaave’s syndrome, which complicates early diagnosis and decision making. Clinical observation of two patients with Boerhaave’s syndrome is presented. One patient was hospitalized 7 hours after the onset of pain in the upper left side, nausea, vomiting. Clinical examination, ultrasound and chest X-ray revealed no pathology. However, after 3 hours, the patient’s condition deteriorated sharply, emphysema of the neck and chest appeared. X-ray revealed left-sided pneumohemothorax. Thoracotomy revealed a 3.5-cm long rupture in the lower third of the esophagus on its left lateral wall, which was sutured. The chest cavity and mediastinum are debrided and drained using tubes. A gastrostomy was formed. The postoperative period was complicated by multiple organ failure and sepsis. Patient was in the intensive care unit for 29 days. The esophageal wound healed on the 46th day and the patient was discharged for outpatient observation. Another patient was hospitalized three hours after onset of illness with a left-sided pneumohemothorax and acute abdomen symptoms. Chest tube on the left was placed and a dark brown liquid released under pressure. The peritonitis clinical symptoms prompted surgeons to perform urgent laparotomy during which no pathology of the abdominal organs was detected. Only after computed tomography, a rupture of the esophagus was diagnosed. As a result of delayed surgery, infection complications and sepsis developed, which led to the patient’s death.

Percutaneous Endoscopic Gastrostomy with T-Fasteners versus "Pull Technique": Analysis of Complications.

The T-fasteners gastrostomy (T-PEG) has become increasingly popular over recent years as an alternative to the "pull-technique" gastrostomy (P-PEG). This study aimed to compare P-PEG and T-PEG complications. A retrospective observational study of pediatric patients who underwent percutaneous endoscopic gastrostomy (PEG) placement. P-PEG was performed using the standard Ponsky technique and was replaced after 6 months by a balloon gastrostomy under sedation. T-PEG was performed using three percutaneous T-fasteners (that allow a primary insertion of a balloon gastrostomy). The balloon was replaced by a new one after 6 months without sedation. Complications were recorded. In total, 146 patients underwent PEG placement, 70 P-PEG and 76 T-PEG. The mean follow-up was 3.9 years (standard deviation = 9.6). Age, weight, and associated comorbidities were comparable (p > 0.05). The overall complications were 17 (24.2%) in the P-PEG group and 16 (21.0%) in the T-PEG group (p > 0.05). P-PEG was associated with more sedation for button replacement (97 vs. 2.6% [p < 0.05]). P-PEG was associated with more early tube dislodgement during the first replacement (7.2 vs. 1.4% [p = 0.092]). Two of the five dislodged gastrostomies in the P-PEG group underwent laparotomy due to peritonitis, whereas the only dislodged gastrostomy in the T-PEG group was solved endoscopically. Altogether, P-PEG was associated with more complications that required urgent endoscopy, laparotomy, or laparoscopy (18.6 vs. 6.6% [p < 0.05]). P-PEG was associated with more sedation, complications during first button replacement, and complications requiring urgent endoscopy, laparotomy, or laparoscopy compared with T-PEG.

Characteristics of Bleeding Peptic Ulcers and the Outcome after Endoscopic Therapy at a Tertiary Care Centre of Pakistan

Peptic ulcers are a global health concern. Bleeding episodes, a common complication require urgent intervention. Endoscopic therapy for managing bleeding peptic ulcers offering both diagnostic and therapeutic benefits. Objective: To analyze the characteristics of bleeding peptic ulcers and assess the outcomes following endoscopic therapy. Methods: A descriptive case series was conducted at Lahore General Hospital (LGH) between June 2021 and January 2022. Patients aged 18-80 with upper GI bleeding due to peptic ulcers or undergoing endoscopy with bleeding peptic ulcers were included. An 80mg bolus of omeprazole was given, followed by infusion at 8mg per hour and an urgent endoscopy was planned. Patients were observed for re-bleeding for 72 hours post-endoscopy. Results: Out of total 100 patients with upper GI bleeding, 70% of patients were male and 30% were female. The most common diagnosis was duodenal ulcers (75%), with the anterior wall being the most common site (86.67%). Dual therapy was administered in all patients, with hemostatic clips being applied in 68% of patients and electrocoagulation heat therapy being used in 32% of patients. Initial hemostasis was successful in 88% of patients treated endoscopically. But, 12% of patients experienced heavy bleeding during endotherapy and out of these, 8 patients required urgent laparotomy. Patients needed a second look endoscopy, 4 patients requiring angiographic embolization and 6 being managed with endotherapy. Conclusion: Dual therapy, hemostatic clips and electrocoagulation heat therapy are effective in achieving initial hemostasis in most cases

The Used of Magnetic Resonance Imaging in Managing Intra-Abdominal Pregnancy: A Case Report

Most women will experience a normal pregnancy process. However, there are some complications that may occur during the pregnancy. Pregnancy outside of the uterus is also known as intra-abdominal pregnancy. Intra-abdominal pregnancy is among the complications during pregnancy that are commonly reported besides abortion, Pregnancy Induced Hypertension (PIH) and Gestational Diabetes Mellitus (GDM). These complications are believed to be the main cause of the increase in maternal and perinatal death rate. Therefore, the used of appropriate diagnostic imaging in management of obstetric cases should be focused. Thus this case study is intended to evaluate the used of Magnetic Resonance Imaging (MRI) in managing intra-abdominal pregnancy. The study focused on one case of abdominal pregnancy which continued into the second trimester. A 30-year-old woman, G2 P0+1 at 12-13 weeks’ gestation presented to public hospital complaining of recurrence epigastric pain with no history of vaginal bleeding. An MRI was performed and the mother was identified as having an intra-abdominal pregnancy. Urgent laparotomy done. Intraoperative noted heamoperitoneum with active bleed seen from the placenta that adhere to the omentum. Partial omentectomy was done. The fetus about 14 week’s gestation are seen and removed. Case studies have proven that the option to perform an MRI on a suspected intra-abdominal pregnancy can help provide information to establish an accurate diagnosis and appropriate patient care management. Therefore, the use of MRI is highly recommended for all cases that are expected to experience intra-abdominal pregnancy as to save the patient and as well as to avoid obstetric complications.

Abdominal versus pelvic gunshot injuries in terms of postoperative outcomes: A cohort representing the experience of 406 cases in seven years.

Gunshot injuries have become a significant problem globally. This study aimed to assess the differences between abdominal versus pelvic gunshot injuries in terms of postoperative outcomes to determine which type of injury is more lethal. This was a cohort study carried out to compare patients who had abdominal versus pelvic gunshot injuries, to analyse the differences in the impact of the anatomical site of injury on morbidity, mortality, and disabilities in all patients who had been admitted to the hospital due to torso gunshot injuries from February 2011 to December 2018. During the study period, 406 patients suffered from torso gunshot injuries. 391 were males and 15 were females; 343 (84.4%) patients had abdominal gunshot wounds, which were considered the first group, while in the second group, there were 63 (15.6%) patients who had pelvic gunshot wounds In the first group, 328 (95.6%) patients required urgent explorative laparotomy, complications were observed in 83 (24.2%) patients, while re-operations were reported in 51 (14.9%) patients and 11 (3.2%) patients had permanent functional disabilities, and 46 (13.4%) patients passed away. In the second group, all patients were treated with urgent explorative laparotomy, 17 (27%) patients suffered from complications, re-operation occurred in 13 (20.6%) patients, permeant functional disability occurred in 17 (27%) patients, and mortality was seen in 16 (25.4%) patients. Our clinical experience has shown that mortality rates and long-term disability occur at a higher rate in pelvic gunshot injuries therefore early senior surgeon input is mandatory for the potential poor outcome to be minimized.

A49 AN UNEXPECTED CASE OF SEVERE PROTEIN-LOSING ENTEROPATHY IN A TODDLER

Abstract Background Protein-losing enteropathies (PLE) are characterized by excess loss of serum proteins into the gastrointestinal tract, resulting in hypoproteinemia, peripheral edema, and related respiratory and cardiac sequelae. PLE should be suspected in patients with hypoproteinemia not explained by protein malnutrition, impaired hepatic protein synthesis, or renal losses, and can occur as a consequence of erosive or non-erosive gastrointestinal diseases, and conditions that alter lymphatic flow. Aims To present a case of intestinal malrotation with chronic volvulus presenting as PLE. Methods In this report, we describe a pediatric patient presenting with PLE ultimately found to have intestinal malrotation with chronic volvulus. Results A healthy 1-year-old male presented with acute non-bloody diarrhea and peripheral edema on a background of recurrent colicky abdominal pain and non-bilious emesis. He had significant electrolyte derangements at presentation including hypokalemia, hyponatremia, hypomagnesemia, and metabolic acidosis, with additional laboratory findings of hypoalbuminemia (11g/L), hypogammaglobulinemia (IgA 0.11g/L, IgG 0.77g/L, IgM 0.28g/L), lymphopenia (0.4x10E9/L), and fat-soluble vitamin deficiency (Vitamin A 0.5umol/L, 25-Hydroxyvitamin D 18.4nmol/L, Vitamin E 6umol/L, INR 1.7). In addition to abdominal imaging, he underwent endoscopic evaluation which did not identify an underlying etiology. As his presentation was consistent with PLE, a high-protein, low-fat diet was initiated. Despite dietary adherence for 16 weeks, the PLE features persisted with ongoing severe hypoalbuminemia (20g/L). Given a suspicion of intestinal lymphangiectasia, a capsule endoscopy was arranged. In the interim, the patient had recurrence of abdominal pain and emesis prompting a repeat abdominal ultrasound which demonstrated swirling of the mesenteric vessels in the midline. An upper gastrointestinal series identified a short mesenteric root with the duodenojejunal junction and cecum in proximity. Urgent laparotomy confirmed a 720-degree volvulus of the small bowel around the mesenteric root, with an abnormally positioned duodenojejunal flexure and cecum. This was presumed to be chronic given the absence of acute vascular compromise. The patient underwent a Ladd procedure. He had complete resolution of symptoms and PLE features on a liberalized diet. Conclusions This report identifies a case of intestinal malrotation with chronic volvulus presenting as PLE, highlighting an atypical presentation of intestinal malrotation outside the neonatal period. Awareness of these atypical presentations is important to facilitate prompt diagnosis and treatment, thereby reducing the rate of complications. Funding Agencies None

Gastric Rupture as Complication of Heimlich Maneuvre: Case Report

Background: Foreign body airway obstruction (FBAO, a.k.a. choking) is life-threatening situation, which requires an instant intervention. Among techniques to eliminate foreign body and relieve obstruction, most used is Heimlich maneuver. However, it can itself cause severe damage. Case Description: We report case of gastric rupture after successful foreign body elimination. Clinical signs were weak, diagnosis was based mostly on radiological evidence of wast quantity of free air in abdominal cavity. Urgent laparotomy revealed gastric rupture, repaired with hand-sewn sutures. Conclusions: Complications due the resuscitation, although rare, can be life threatening, so should be taken into account in every case. Public awareness and knowledge about aid and self-aid in case of choking could be improved.

Management of massive hemothorax resulting from traumatic diaphragm rupture with kidney avulsion injury by combined anterior thoracoabdominal approaches

Abstract Blunt trauma resulting in diaphragm rupture, kidney avulsion injury, and subsequent hemothorax is rare and requires immediate surgical intervention. After diagnosis, urgent laparotomy with thoracotomy is needed to control renal bleeding. However, because of limitations in imaging studies, confirming this diagnosis is not straightforward, thus underscoring the importance of proper patient’s posturing. It is recommended that in cases of massive hemothorax combined with intra-abdominal bleeding, no matter performing thoracotomy or laparotomy first, the attending surgeons have to put patients in a position appropriate for simultaneous thoracoabdominal approach. It avoids surgical delays that could lead to fatal outcomes.